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The graph below allows you to compare your prescribing of zopiclone to patients of different ages compared with your peers over the last
12 months of available data (July, 2017 to June, 2018). This is standardised to a rate of dispensing per 1,000 patients, and excludes patients
who received less than 20 tablets, who may have been prescribed a short course of zopiclone for insomnia, e.g. due to acute distress.
The denominator is all patients who were dispensed a medicine during this time where the prescription was written by you, i.e.
it excludes patients who you may have seen but who were not dispensed any subsidised medicine during this time.
Your comparator is the average prescribing rate of ten general practitioners who prescribed to patients with a similar gender,
age and ethnicity distribution as patients you prescribed to.
Figure A: Patients dispensed at least 20 tablets of zopiclone in a year across different
age bands from July, 2017 to June, 2018, per 1,000 patients who were dispensed any medicine during this time.
Dispensing of high volumes to patients prescribed zopiclone by you
The figure below shows dispensing of high volumes of zopiclone, of 180 tablets or more, by patient age from July, 2017 to June, 2018 for you,
compared to your peers and national dispensing rates. You may wish to audit your practice’s records to identify patients with high
use who could benefit from attempting to withdraw from using zopiclone.
For an audit on identifying patients who may benefit from discussing
the risks associated with continued use of hypnotic medicines, see:
https://bpac.org.nz/Audits/insomnia.aspx
Figure B: Number of patients dispensed 180 tablets or more of zopiclone per 1,000 people
who received any dispensing from July, 2017 to June, 2018.
To download a printable version of your prescribing
reports, go to the reports section of My bpac
Your practice’s prescribing of zopiclone by patient age
Wrong practice? Update your details
The graph below allows you to compare your prescribing of zopiclone to patients of different ages compared with your peers over the last 12 months
of available data (July, 2017 to June, 2018). This is standardised to a rate of dispensing per 1,000 patients, and excludes patients who
received less than 20 tablets, who may have been prescribed a short course of zopiclone for insomnia, e.g. due to acute distress.
The denominator is patients of the same age who were enrolled in your practice over this time. Your comparator is the average
prescribing rate of ten practices whose patient populations are similar to yours in: gender, age, deprivation and ethnicity.
Figure A: Patients per 1,000 population dispensed at least 20 tablets of
zopiclone across different age bands from July, 2017 to June, 2018.
Dispensing of high volumes to patients prescribed zopiclone by your practice
The figure below shows dispensing of high volumes of zopiclone, of 180 tablets or more, by patient age for your practice over the last 12 months,
compared to your peers and national dispensing rates. You may wish to audit your practice’s records to identify patients with high use
who could benefit from attempting to withdraw from using zopiclone.
For an audit on identifying patients who may benefit from discussing the risks associated with
continued use of hypnotic medicines, see: https://bpac.org.nz/Audits/insomnia.aspx
Figure B: High volumes of zopiclone dispensing. Number of patients per 1,000 population
dispensed 180 tablets or more of zopiclone from July, 2017 to June, 2018, with prescriptions written by your practice, your peers and nationally.
To download a printable version of your prescribing
reports, go to the reports section of My bpac
Hypnotic medicines are prescribed for a variety of conditions; zopiclone and shorter-acting benzodiazepines, such as temazepam, are the predominant
hypnotics used for managing insomnia. Zopiclone is the most widely used hypnotic medicine in New Zealand and has consistently been one of the highest
prescribed medicines in general; it was the 14th most prescribed medicine in 2017, with 570,000 dispensings.1
The high rate of prescribing of zopiclone in New Zealand likely arises from it originally being promoted as a safer alternative to benzodiazepines.
However, zopiclone affects the same neurotransmitter systems as benzodiazepines and is associated with many of the same adverse effects, such as falls and fractures, and
cognitive effects the day after use.2 Previous investigations had highlighted a potential association between zopiclone use and dementia,3 however, these findings are debated in the wider literature and the conclusions are potentially susceptible to confounding. Subsequent analysis in middle-aged and older patients with chronic insomnia has not confirmed this link, demonstrating no increased risk of dementia or long-term cognitive decline.4 Nevertheless, caution is still advised when prescribing zopiclone, particularly for longer durations of use, due to the risk of addiction, tolerance and withdrawal symptoms.4
Use non-pharmacological approaches first for treating insomnia
Despite their high rate of use, hypnotic medicines are not the preferred treatment approach for patients with insomnia.5 Non-pharmacological approaches,
such as sleep hygiene techniques or restricting time in bed, result in improvements which are as good, or better than, hypnotic medicines.5 Although
hypnotic medicines may produce quicker improvements in sleep in the first few weeks of use, the balance of benefits to risks may not be favourable for
some patients.6,7 Patients can become dependent on taking hypnotic medicines in order to sleep; this can happen over a short time period, with some
studies reporting rebound insomnia and withdrawal symptoms such as agitation and anxiety after two to three weeks of use.8
Hypnotic medicines should only be considered for patients with severe symptoms or an acute need, such as difficulty sleeping following a traumatic event.
Ideally, if hypnotic medicines are prescribed they should be used for short periods, e.g. ten days or less, and
used alongside non-pharmacological approaches to improve sleep (see: “Safe prescribing of hypnotic medicines”).9
Prescribing is not just in older people
Most general practitioners in New Zealand are likely to have patients in their practice who have been taking hypnotic medicines long-term.
These patients are typically thought of as being older, e.g. aged over 65 years, and may have initially been prescribed hypnotic medicines by
another doctor or at another practice many years ago.
However, dispensing data show that many younger people in New Zealand are prescribed zopiclone. Dispensing across different age groups has remained relatively
steady over the last five years (standardised by population - Figure 1).
These data indicate that people start to seek help for sleeping from age late 20s onwards. The highest rates of dispensing
are for older patients, who are also those at the greatest risk of harm from adverse effects such as falls. If younger patients become dependent on
using hypnotic medicines for sleep, they face a large cumulative risk from ongoing use as they get older.
Figure 1: Patients per 1,000 population dispensed at least 20 tablets of zopiclone in a year across different age bands from 2013-2017.
The latest 12 months of available data (July, 2017-June, 2018) show that people of European/Other ethnicity have the highest rates of
dispensing (Figure 2).
Figure 2: Dispensing rates per 1,000 population of at least 20 tablets of zopiclone from July,
2017 to June, 2018, by ethnicity, for patients aged 18-65 years.
Hypnotic medicines should ideally be prescribed in short courses, e.g. ten days or less, used only as needed,
and initiated with an exit plan in place from the beginning to prevent ongoing use.
Dispensing data from the last 12 months show that many patients are prescribed zopiclone for more than four weeks: 60% received more than
30 tablets in the 12 month period, and 20% received 180 tablets or more; enough for at least one tablet every second
night (Figure 3).
Figure 3: Number of zopiclone tablets dispensed to patients from July 2017 to June 2018.
High use also occurs in younger patients
Although long-term use of hypnotic medicines is often thought of as a problem occurring in older people, Figure 4 shows that younger people
are also prescribed high volumes of zopiclone. Of patients who received more than 180 tablets of zopiclone in the last 12 months, 26%
were aged 55 years or under, and 12% aged 45 years or under.
Figure 4: Number of patients per 1,000 population dispensed 180 tablets or more of zopiclone from July 2017 to June 2018.
Safe prescribing of hypnotic medicines
Consider these strategies when prescribing hypnotic medicines to avoid the potential for escalating use:5,10,11
- Ensure non-pharmacological approaches are initiated at the same time, such as sleep hygiene or time in bed restriction
- Assess whether patients have factors which contribute to a higher risk of prescribing, such as a history of substance
misuse, concurrent mental illness or concurrent use of medicines which add to the risks of adverse effects, such as opioids
- Discuss with patients that evidence shows that hypnotics only provide benefits over and above non-pharmacological approaches
for the first few weeks, and that long-term use is associated with adverse outcomes, including motor vehicle accidents,
falls and potentially an increased risk of dementia in older age
- Have an exit plan and agreed length of treatment from the beginning: Emphasise to patients that treatment of insomnia
with hypnotic medicines is a short-term approach, they are not intended for ongoing use, and they should not be used every
night, e.g. have a break after three consecutive nights' use
- Advise patients to try to fall asleep first (using sleep hygiene techniques), and then only take a hypnotic medicine
if they remain awake, e.g. after two hours
- Prescribe short courses, e.g. ideally for a maximum of ten days or less; indicate the number of tablets on the prescription
rather than “as needed”.
- Review the patient’s need for pharmacological treatment before issuing repeat prescriptions. The review should cover
their use of non-pharmacological approaches and any adjustments that may need to be made, e.g. to sleep hygiene or sleep
restriction practices.
- Advise patients to withdraw a hypnotic slowly if they have been using it for longer than a few weeks; suddenly stopping
use can cause withdrawal symptoms, leading to reinitiating hypnotic medicines and reluctance about stopping again in the
future.
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